Informed Consent for Compounded GLP-1 and GLP-1/GIP Medications

I understand that the following possible side effects may occur. This is not an all-inclusive list. For more information on this medication, you may consult with your prescriber, pharmacist, or other healthcare practitioner,

Most Common Side Effects: Nausea, Vomiting, Diarrhea, Constipation, Abdominal Pain, Headache, Fatigue, Dyspepsia, Dizziness, Abdominal Distention, Belching, Hypoglycemia, Flatulence, Gastroenteritis, Gastroesophageal Reflux Disease, Injection Site Reactions (itching or burning at site of administration with/without thickening of the skin).

Less Common but Serious Side Effects: Pancreatitis (inflammation of the pancreas), hypoglycemia (low blood sugar), acute gallbladder disease including gallstones, acute kidney problems (kidney failure), serious allergic reactions (including swelling of your face, lips, tongue, or throat, severe rash or itching, very rapid heartbeat, problems breathing or swallowing, or fainting or feeling dizzy), change in vision in people with type 2 diabetes, increase in heart rate (heart racing that lasts for several minutes), depression, or thoughts of suicide.

BLACK BOX WARNING: RISK OF THYROID C-CELL TUMORS

This medication has been found to cause a specific type of thyroid tumor (thyroid C-cell tumors) in rats and mice. It’s not known if this medication can cause similar tumors in humans. Discuss the benefits and risks of this treatment with your clinician. This medication should NOT be used by people with a personal or family history of medullary thyroid carcinoma (MTC) or those with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While using this medication, contact your clinician immediately if you notice any signs of thyroid tumors, such as an unusual growth or lump in the neck, difficulty swallowing, shortness of breath, or persistent hoarseness.

I understand that certain drug interactions may occur.

I give consent for the GLP-1 agonist or GLP-1 agonist + GIP prescription and the anticipated dosage range. I also indicate that I understand the following:

This medication consent is effective immediately. The need for and continued prescriptions for this medication will be reviewed at the clinician’s discretion. I can refuse to give consent or can withdraw my consent at any time with written notification to my assigned clinician. This will not affect my right to change my decision at a later date. If I refuse to give consent or withdraw consent, I will not be eligible to receive a prescription for a GLP-1 agonist prescription.

I understand this prescription comes from a compounding pharmacy and is not FDA approved. I understand this medication could be harmful if taken inappropriately and should be used only as prescribed. I acknowledge that no guarantees have been made to me concerning my results. My consent permits the dose to be changed within the anticipated dosage range without signing another consent. Additionally, medication may be transitioned to another GLP-1 medication (Semaglutide to Tirzepatide/ Tirzepatide to Semaglutide) depending on response to medication/ side effects.

I certify that I have read the contents of this form in its entirety. I have had the opportunity to ask questions and have had my questions answered. I understand the benefits and risks of the medication. I understand that my receipt of this medication is subject to reporting, by my pharmacy, to the prescribing physician, and/or the manufacturer, if required, and I authorize these disclosures. I am 18 years of age or older and authorized to execute this consent form. By signing this form, I voluntarily give my consent for treatment and agree to the risks.